Synopsis The small open sight-seeing boat TAN 1 departed Anse aux Basques, Quebec, at about 1515, 12 September 1993, with 13 persons on board, including the operator, on a sea mammal-watching cruise on the St. Lawrence River near Les Escoumins, Quebec. The cruise was expected to last approximately three hours. At about 1750, following a mechanical failure, water began to flood the deck, waves broke over the stern, and the TAN 1 capsized. The operator of the boat and the passengers ended up in the water, but they were quickly rescued by other sight-seeing boats in the area. The Board determined that the outboard motors of the TAN 1 stalled and could not be restarted because the fuel was contaminated with water. Shortly thereafter, the drifting boat was flooded by the stern and eventually capsized. 1.0 Factual Information 1.1 Particulars of the Vessel 1.1.1 Description of the Vessel The TAN 1 is an open boat constructed of a sandwich of fibreglass over a balsa wood core. The steering position and the control console are located aft. This boat, which does not carry more than 12 passengers, is used mainly in the summer for sea mammal-watching cruises in the vicinity of Les Escoumins. 1.2 History of the Voyage On 12 September 1993, the passengers reported to the company's shed where they were issued wetsuits and were briefed on the type of tour that they were about to take on the TAN 1. At about 15003, the passengers proceeded to the Anse aux Basques pier and boarded the boat. Before departure, the operator explained to the passengers that they had to remain seated throughout the cruise except when the boat was stationary for watching sea mammals. The passengers were not, however, briefed on the location or use of the lifejackets carried on board. The jackets were kept in an underdeck locker, but there was no indication of where they were stowed. At 1515, the TAN 1 departed Anse aux Basques with 12 passengers and the operator on board bound for the watching sites. The boat ran along the north shore between Pointe Otis and Pointe Crapaud, Quebec, in search of sea mammals. The south-west winds picked up speed, and the sea became increasingly choppy. At about 1700, the TAN 1 was travelling at high speed in heavy seas and was being tossed from wave crest to wave crest. While a wave larger than the others was being taken, all the passengers were lifted from their seats and then somehow fell back down on them; one of the passengers fell on the edge of a bench. The operator put the motors in neutral and helped this passenger, who complained of pain at the base of her spine. Her legs were paralyzed with pain and gave way under her; she was settled on one of the benches in front of the steering position. The operator offered to go back to port, but the passenger refused, because she did not want to end the cruise. The operator returned to the steering position and found that the starboard motor had stalled, but he was able to restart it. The cruise continued at reduced speed. Waves were breaking over the stern and began to flood the opening in the transom. The starboard motor stalled again and the boat turned sideways to the waves. The operator used the port motor to straighten the boat head on to the sea. While he was trying to restart the starboard motor, the port motor stalled in turn. Noting that the boat was sinking deeper and deeper by the stern, the operator asked the passengers to move to the bow, so as to raise the stern. While the operator was busy trying to restart the motors, the passengers asked him for containers to bail with, but he told them that he had none, and that it was too late anyway. The flooding continued and the passengers were up to their knees in water when the water accumulating in the bottom of the boat lifted the lid of the underdeck locker, and the passengers found the lifejackets. It was 1750. Some passengers grabbed the jackets while the operator transmitted a very high frequency (VHF) radio call to the pilot boat ABRAHAM MARTIN requesting assistance. In the meantime, another Zodiac-type sight-seeing boat operated by the same company, the TAN 3, headed toward the TAN 1 to lend assistance. Before the TAN 3 could reach the TAN 1, the latter capsized and sank by the stern, throwing all the occupants into the sea; some with their lifejackets unfastened, others with no lifejackets on at all. Three passengers managed to cling to the bow of the TAN 1, but others were sent adrift. Vessel Traffic Centre (VTC) Les Escoumins was alerted and it advised the sight-seeing boats in the area. The 13 occupants of the TAN 1 were quickly pulled from the icy waters of the river, and, by 1805, all were safe and sound. When the boats arrived at the Anse aux Basques pier, an ambulance was waiting, and four occupants who were suffering from hypothermia were taken to hospital in Les Escoumins. 1.3 Injuries The passengers were rescued safe and sound, although some of them had to be hospitalized to receive treatment for hypothermia due to immersion in cold water. The water temperature is estimated to be 15C during the summer at this location. 1.4 Vessel Certification and Equipment As a five-ton boat, the TAN 1 was not required to undergo regulatory inspections by the Ship Safety Branch of the Canadian Coast Guard (CCG). However, on 13 August 1993, following another marine occurrence, the CCG had forbidden the TAN 1 from engaging in cruises because of equipment that did not comply with the Small Vessel Regulations or was missing altogether. On 19 August 1993, as the owner had obtained his radio licence and the equipment was in compliance with the requirements laid down in the Small Vessel Regulations, the CCG had lifted the detaining order. 1.4.1 Operator's Certification and History The Canada Shipping Act (CSA) does not require the master of a vessel not over five tons that carries not more than 12 passengers to be certificated. The operator in charge of the TAN 1 at the time of the accident has worked as a fisherman since 1974. He holds a Canadian Class 4 Small Fishing Vessel Master's Certificate issued in 1983, and has attended a Marine Emergency Duties (MED) course. He occasionally works as master of small passenger-carrying boats in the area of Les Escoumins. 1.5 Weather Information At the time of the accident, the weather was clear, visibility was good, the winds were from the south-west at between 15 and 25 knots, and the water and air temperatures were 15C and 12C respectively. At 1600 on the day of the occurrence, the Quebec Meteorological Centre of Environment Canada issued a small vessel warning because of strong winds. The operator of the TAN 1 heard the warning on his VHF radio, but he felt that he was sheltered from the wind and therefore continued the cruise. The height of the waves was estimated at approximately one or two metres. 1.6 Life-saving Equipment and Clothing There were 13 lifejackets on board the TAN 1, and, when the wreck was found in the Gulf of St. Lawrence on 26 September 1993, 4 were found still in the locker. The passengers found the lifejackets when the lid of the locker was lifted by the pressure of the water accumulated in the bottom, just a few minutes before the boat capsized. According to evidence from the passengers, there was no indication of where the lifejackets were stowed. Furthermore, the passengers had received no pre-departure briefings on the use of the lifejackets. All the passengers were wearing a wetsuit/worksuit in more or less good condition. Some suits had holes in them, and others were threadbare or missing Velcro fasteners at the ankles and wrists. The boat's operator was wearing a Mustang vest and rubber boots. 1.7 Radio Communications The operator of the TAN 1 did not issue a distress call on channel 16 of the VHF radio; instead, he used channel 9 to call the pilot boat ABRAHAM MARTIN, and channel 10 to inform that vessel that the TAN 1 had a large ingress of water and that there were 12 passengers on board. This call was picked up by VTC Les Escoumins at 1751. The capsized boat could be seen at the Les Escoumins radar station. At 1752, VTC Les Escoumins alerted other sight-seeing boats in the vicinity of the sinking, and, at 1755, a Mayday Relay was broadcast for a capsized boat with 12 passengers on board off Anse aux Basques. At 1805, the VTC was informed that all the occupants of the TAN 1 had been rescued, and the ABRAHAM MARTIN requested that an ambulance stand by at Anse aux Basques. 1.8 Rescue After being informed of the accident, the ABRAHAM MARTIN and the Zodiac-type inflatables RORQUAL and MARSOUIN rescued one person apiece, and the TAN 3 rescued 10. 1.9 Calculation of Trim The stability conditions of the TAN 1 were calculated based on the weight of the passengers and the operator, and of the maximum fuel load. The weight of the TAN 1 on departure was 3,200 kg with a trim by the stern of 0.12. The stern freeboard at the time was 116 mm. After 2 hours and 45 minutes of operation, the fuel load had decreased, and the weight of the boat was 3,150 kg on an even keel; the freeboard was then 184 mm. The overhung outboard motors had been bolted on to a structure 686 mm from the transom. They could not be mounted right on the transom because the axis of the propellers was too close, thus creating a problem in bringing enough water to the propellers. 1.10 TSB Engineering Laboratory Report In their statements, all witnesses agreed that greyish smoke issued from the exhaust pipes of the motors even before they stalled. This indicates the presence of water in the fuel. Furthermore, the TSB Engineering Laboratory examined the two outboard motors of the TAN 1 and noted, among other things, traces of prolonged contamination and deposits of salt and other substances in the fuel supply systems at the carburettors and other components. The substances contaminating the fuel had to have come from the fuel tank. Several deficiencies were noted in the design of the tank, which quite clearly did not meet the Construction Standards for Small Vessels, Part IV.